Provider Demographics
NPI:1548539752
Name:SMITH, LISA J (LMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1900 NE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-3119
Mailing Address - Country:US
Mailing Address - Phone:954-415-6285
Mailing Address - Fax:954-782-6564
Practice Address - Street 1:1915 NE 45TH ST
Practice Address - Street 2:SUITE 104B
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-5199
Practice Address - Country:US
Practice Address - Phone:954-415-6285
Practice Address - Fax:954-782-6564
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA56206225700000X
FLMM27808225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist